Acupuncture for Arthritis
Acupuncture for Arthritis
By Sharon L. Kolasinski, MD, FACP, FACR
Acupuncture has been in use as an analgesic for centuries and its application to the treatment of arthritis pain remains a frequent one. In the 1970s, President Nixon’s overtures to China led indirectly to the introduction of many aspects of traditional Chinese medicine into the popular consciousness, if not into mainstream medical practice. Since then, acupuncture has become one of the most widely accepted of the traditional methods and continues to grow in availability. Its use in the treatment of depression,1 postoperative dental pain,2 nausea,3 and fibromyalgia4 has recently been reviewed.
Mechanism of Action
Understanding the mechanism of action of acupuncture depends to some extent on the background and assumptions of who is offering the explanation. In traditional Chinese medicine, the mechanism is thought to involve alterations in the flow of qi by the placement of acupuncture needles in well-defined locations on the skin. This interpretation of the mechanism of action assumes that qi, or vital energy, flows along routes, or meridians, throughout the body and that the flow is disrupted by illness. The imbalance in the flow of qi can then be restored by the insertion of the needles, with resultant improvement in health.
If one assumes a Western pathophysiologic model, the most frequently cited mechanism of action for the analgesic properties of acupuncture involves inducing endogenous opioid production or altering pain neurotransmitter release.5,6 Experimental evidence shows that some of acupuncture’s analgesic effects in dental pain can be blocked by naloxone, substantiating the argument that opioid production occurs with the use of acupuncture.7 The use of oral narcotics along with acupuncture improves upon the pain relief provided by acupuncture alone.8 Stimulation by acupuncture needles also may stimulate the hypothalamus and pituitary gland, altering neurotransmitter and neurohormone secretion and central and peripheral blood flow.5
Methodological Difficulties
The appropriate choice of a placebo in acupuncture research continues to make interpretation of controlled trials problematic (see Table 1, below). Since the mechanism of action is incompletely understood, it remains difficult to know what the most reliable placebo would be. Some of the effects of acupuncture appear to be nonspecific and may be induced by sham acupuncture as well. Furthermore, blinding of both patients and investigators remains difficult to accomplish. This dilemma has led to a variety of creative solutions, including the development of devices that permit skin contact without penetration by an acupuncture needle. The acupuncturist may be blinded using some of these devices as well. Studies using these methodological innovations are in progress.
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Table 1 |
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Methodological challenges of acupuncture studies23,24 |
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• Appropriate and adequate treatment (a sufficient number of points stimulated per treatment, adequate frequency and duration, adding extra stimulation of acupoints using electroacupuncture or moxibustion, and fixed regimens stimulating predetermined acupoints vs. individualized treatments); • Appropriate comparison groups; • Blinding of patients and practitioners (although the latter of which is impossible, assessors blinded to treatment group can be used for objective measures); • Adequate sample sizes; • Adequate assessment of outcomes (validated subjective and objective measures); and • Adequate duration of trial and follow-up. |
NIH Position
In 1998, the National Institutes of Health (NIH) convened a Consensus Development Panel to provide "a responsible assessment of the use and effectiveness of acupuncture to treat a variety of conditions." The panel reviewed thousands of publications from 1970 to 1997. They concluded that there was "a paucity of high-quality research assessing the efficacy of acupuncture" and that there are numerous problems with interpretation of the available literature. These include difficulties with study design, sample size, and controls. However, they concluded that areas in which acupuncture "may be useful as an adjunct treatment or an acceptable alternative or be included in a comprehensive management pro- gram" include tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low back pain, and carpal tunnel syndrome.
Clinical Studies: Osteoarthritis
One of the earliest studies to assess the role of acupuncture in the treatment of osteoarthritis (OA) pain was published in the New England Journal of Medicine in 1975.9 In this study, 40 patients with OA of the hip, knee, spine, or hands were randomly assigned to receive acupuncture or placement of acupuncture needles on sites contiguous to actual acupuncture points. Each patient received a total of eight treatments. All those undergoing acupuncture were said to experience de qi, the sensation of numbness, tingling, or heaviness frequently reported by treated patients, and all those undergoing sham acupuncture, reportedly, did not. Subjective and unvalidated outcome measures were used to assess patient response. Subjects improved, regardless of treatment, according to physicians’ evaluations of joint tenderness and joint range of motion and in patients’ own evaluations of pain and mobility. The authors concluded that they could demonstrate no difference between acupuncture and the problematic placebo used.
A review of additional randomized, controlled trials for OA symptoms has shown no difference between acupuncture and sham acupuncture. However, none of these studies have been sufficiently powered to detect a difference between actual and sham intervention. Furthermore, in each study, both groups improved, underscoring the point that any needle puncture may evoke an analgesic response.10
One study used delayed vs. immediate acupuncture in a group of 32 Danish patients severely affected by OA.11 Participants were drawn from those subjects awaiting total knee replacement. Half were randomly assigned to receive acupuncture treatments twice weekly for three weeks; the other half were treated in the same manner eight weeks later. Outcome measures included standard tests of function, such as walking and climbing stairs, as well as a visual analog scale (VAS) assessment of pain. Patients undergoing acupuncture experienced significant reductions in VAS scores and use of non-steroidal anti-inflammatory drugs (NSAIDs). Participants who experienced benefit were invited to continue to receive acupuncture treatments. Of the 22 who did derive benefit and received continued treatment, seven decided to forego surgery.
A more recent study used a similar design to assess not only response to therapy but also the demographic and medical characteristics of patients that might predict response.12 The investigators assessed 74 patients during eight weeks of twice weekly treatment. Acupuncture reduced pain at week 4, week 8, and week 12, four weeks after completion of the treatment. No patient experienced an adverse effect. The effectiveness of acupuncture was not correlated with any demographic factor assessed, including age and sex. The severity of symptoms at baseline was predicted by the duration of disease; however, patients across the spectrum of disease severity benefited from acupuncture. Similarly, medical comorbidity did not reduce the effectiveness of acupuncture for analgesia in patients in this study. The investigators did find that the least symptomatic patients were most likely to return to a near-normal level of function and report the absence of chronic pain.
Studies in which drugs were used as a control found mixed results. In a group of 32 patients with OA of the hip, knee, or shoulder, weekly acupuncture provided superior analgesia to the NSAID piroxicam, after the initial two weeks.13 The superiority of acupuncture persisted over the entire eight-week trial. In a group of 58 knee OA patients who were allowed to continue their NSAID, those receiving acupuncture experienced significant improvement in self-reported pain and disability.14 However, in a report on 44 cervical spine OA patients, acupuncture was not better than diazepam in the relief of pain.15
A systematic, best-evidence analysis of the literature on acupuncture for OA of the knee from 1966 to 1999 recently was published.16 Seven randomized trials that did not include electroacupuncture, thermal stimulation, or digital pressure were surveyed. The trials included 393 patients. Based on the quality of the trials, the authors concluded that there was strong evidence that acupuncture was more effective than sham acupuncture for OA knee pain, but that evidence was inconclusive for assessing effect on function. In trials that compared acupuncture with usual treatment or being on a waiting list, however, the evidence was found only to be limited and indicated that acupuncture was superior since these trials were of lower quality. The results of this analysis favored acupuncture more strongly than had the review the previous year,10 but included only two of the same studies as the previous review and used more systematic criteria for study selection and analysis.
Clinical Studies: Rheumatoid Arthritis
Studies of patients with rheumatoid arthritis (RA) are considerably less compelling than are those of patients with OA. The first published study to address the use of acupuncture in RA appeared in abstract form in 1973.17 The study used insertion of needles at sites adjacent to traditionally defined points at superficial depths without "the traditional twirling" as the placebo control. Four of 10 patients subjectively improved over a period of 10 weeks, during which time patients received acupuncture treatment, and then were crossed over to receive "inappropriate" acupuncture. Physical findings improved in only one patient; two patients’ findings progressed and seven were unchanged.
Results were better in a randomized, controlled trial of 10 RA patients with bilateral knee involvement. Subjects received acupuncture treatment on one knee and sham acupuncture on the other. In each patient, analgesia was superior in the acupuncture-treated knee. Interestingly, the sham-treated knee experienced a reduction in pain for an average of 10 hours, while the acupuncture-treated knee averaged 1-3 months of pain relief.18 However, these and most subsequent studies of RA patients are too small and poorly designed to make statistically valid observations about the utility of acupuncture in this disease.10,19
A recent well-designed, randomized, placebo-controlled (using a needle introducer, but no needle, placed at the same acupuncture site as the treatment group) study prospectively crossed over 56 RA patients between treatment and placebo.20 Validated and disease-specific outcome measures were chosen that reflected pain and inflammation. However, only a single point bilaterally, Liver 3 (Li3), was used for treatment over a five-week period. This point was chosen because of its known ability to induce a significant endogenous endorphin response and prior work that suggested analgesic efficacy for headache. This well-conducted trial showed no analgesic or anti-inflammatory benefit to this application of Li3 needling. The authors noted the difference between OA and RA trial results and wondered if they might be explained on the basis of substantial differences in disease pathophysiology.
Adverse Effects
Adverse effects of acupuncture are rare. The NIH Consensus Panel concluded that "the incidence of adverse effects is substantially lower than that of many drugs or other accepted medical procedures used" for the conditions it studied.5
The most comprehensive systematic review of prospective studies addressing acupuncture studies to date concurs that serious complications are rare.21 (See Table 2, below.) However, if pain at the insertion site, bleeding, and a sense of fatigue are considered adverse effects, then minor side effects may be considerable, each sometimes occurring in more than 40% of patients.
The most frequently reported serious complication is pneumothorax, of which approximately 90 cases have been described, two of which were fatal. Of note, one patient treated with acupuncture for OA of the knee developed soft-tissue infection in the calf with Mycobacterium chelonae.22 The Food and Drug Administration mandates the use of single-use, disposable needles.
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Table 2 |
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Incidence of adverse effects of acupuncture21 |
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| Adverse Effect | Prevalence |
| Needle pain | 1-45% |
| Tiredness |
2-41% |
| Bleeding |
0.03-38% |
| Feeling faint/syncope | 0-0.3% |
| Relaxation | ~ 86% |
| Pneumothorax | rare |
| Cardiac tamponade | rare |
Contraindications
Acupuncture treatment has been observed to stimulate uterine contractions and pregnant patients should not be treated. Those with valvular heart disease should avoid insertion of semi-permanent needles. Patients with a bleeding diathesis and those on anticoagulants should avoid acupuncture because of the bleeding risk. Those with implantable cardiac devices, including pacemakers and defibrillators, and those with epilepsy should avoid electroacupuncture. Patients with infectious diseases, including skin infections, should forego acupuncture as well.
Conclusion
Acupuncture appears to be an effective analgesic for the pain of osteoarthritis, but has less support in the literature for effectiveness in treating pain of rheumatoid arthritis. Pain relief in osteoarthritis may be additive to that already provided by medications such as NSAIDs and narcotics, making acupuncture a useful adjunctive therapy in this condition. Side effects are likely to be minimal.
Recommendation
Acupuncture is an option for the treatment of osteoarthritis pain. It may be used alone or in combination with other interventions in a comprehensive management plan. It may be used in both early and late disease. Patients seeking care by acupuncturists should be aware that practitioners are licensed in most states. Information is available regarding physicians practicing acupuncture from the American Academy of Medical Acupuncture (http://www.medicalacupuncture.org). (See sidebar "Acupuncture Regulations in the United States" for more information about certification.)
The role of acupuncture for the management of inflammatory arthritis, such as rheumatoid arthritis, is less clear. It is unlikely to have anti-inflammatory effects, based on the available clinical data, and should be used only as an adjunctive analgesic. Inflammatory arthritis treatment requires specific and intensive use of medications.
Dr. Kolasinski is Assistant Professor of Medicine; Director, Rheumatology Fellowship Program; and Chief of Clinical Service, Division of Rheumatology at the University of Pennsylvania School of Medicine in Philadelphia.
References
1. Gaster, B, Balk J. Acupuncture for treatment of depression. Altern Med Alert 2001;4:5-8.
2. Balk J. Acupuncture for postoperative dental pain. Altern Med Alert 2001;4:89-91.
3. Stolz C. Acupuncture as an antiemetic: Is there a point? Altern Med Alert 2002;5:1-4.
4. Assefi N. Acupuncture for fibromyalgia. Altern Med Alert 2002;5:13-16.
5. NIH Consensus Conference. Acupuncture. JAMA 1998;280:1518-1524.
6. White A. Neurophysiology of acupuncture analgesia. In: E Ernst, White AR, eds. Acupuncture: A Scientific Appraisal. Boston: Butterworth Heinemann; 1999: 60-92.
7. Ernst E, Lee M. Influence of naloxone on electroacu-puncture analgesia using a experimental dental pain test. Review of possible mechanisms of action. Acupunct Electrother Res 1987;12:5-22.
8. Sung YF, et al. Comparison of the effects of acupuncture and codeine on postoperative dental pain. Anesth Analg 1977;56:473-478.
9. Gaw A, et al. Efficacy of acupuncture on osteoarthritic pain: A controlled, double-blind study. N Engl J Med 1975;293:375-378.
10. Berman BM, et al. The evidence for acupuncture as a treatment for rheumatologic conditions. Rheum Dis Clin North Am 2000;26:103-115, ix-x.
11. Christensen BV, et al. Acupuncture treatment of severe knee osteoarthrosis. A long-term study. Acta Anaesthesiol Scand 1992;36:519-525.
12. Singh BB, et al. Clinical decisions in the use of acupuncture as an adjunctive therapy for osteoarthritis of the knee. Altern Ther Health Med 2001;7:58-65.
13. Junnila SY. [Acupuncture therapy of prolonged pain]. Duodecim 1982;98:871-878.
14. Berman BM, et al. Efficacy of traditional Chinese acupuncture in the treatment of symptomatic knee osteoarthritis: A pilot study. Osteoarthritis Cartilage 1995;3:139-142.
15. Thomas M, et al. A comparative study of diazepam and acupuncture in patients with osteoarthritis pain: A placebo controlled study. Am J Chin Med 1991;19: 95-100.
16. Ezzo J, et al. Acupuncture for osteoarthritis of the knee: A systematic review. Arthritis Rheum 2001;44: 819-825.
17. Shen A, et al. A pilot study of the effects of acupuncture in rheumatoid arthritis. Arthritis Rheum 1973;16: 569-570.
18. Man SC, Baragar FD. Preliminary clinical study of acupuncture in rheumatoid arthritis. J Rheumatol 1974;1:126-129.
19. Bhatt-Sanders D. Acupuncture for rheumatoid arthritis: An analysis of the literature. Semin Arthritis Rheum 1985;14:225-231.
20. David J, et al. The effect of acupuncture on patients with rheumatoid arthritis: A randomized, placebo-controlled cross-over study. Rheumatology (Oxford) 1999; 38:864-869.
21. Ernst E, White AR. Prospective studies of the safety of acupuncture: A systematic review. Am J Med 2001; 110:481-485.
22. Woo PC, et al. Acupuncture mycobacteriosis. N Engl J Med 2001;345:842-843.
23. Vincent CA, Richardson PH. The evaluation of therapeutic acupuncture: Concepts and methods. Pain 1986;24:1-13.
24. Hammerschlag R, Morris MM. Clinical trials comparing acupuncture with biomedical standard care: A criteria-based evaluation of research design and reporting. Complement Ther Med 1997;5:133-140.
Kolasinski SL. Acupuncture for arthritis. Altern Med Alert 2002;5:37-42.Subscribe Now for Access
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